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Citation

Chapter 176. Barbiturates

Toxicity from barbiturates has historically been associated with
the highest risk of morbidity and mortality among all sedative-hypnotics.1,2 The therapeutic
use of barbiturates has declined due to the introduction of safer,
less toxic sedative-hypnotics, such as benzodiazepines, and second-generation
anticonvulsants. However, barbiturate overdose and toxicity is still
encountered in the ED. During 2008, the American Association of
Poison Control Centers noted there were 2719 exposures to barbiturates
reported to their centers; 1196 were polydrug exposures that included
a barbiturate, 1523 were single drug exposures to a barbiturate, and
four deaths were identified.3

Barbiturates are typically used in the treatment of seizure disorders,
and for anesthesia induction and procedural sedation.4 They
are used in combination drugs, typically butalbital, for the treatment
of tension and migraine headaches, although the added efficacy of
the barbiturate component is controversial.5,6 Barbiturates
are occasionally used as an adjunct for the treatment of acute and
chronic pain syndromes.7 Severe ethanol and sedativewithdrawal syndromes are typically managed with benzodiazepines,
but barbiturates may have a useful role in combination.8 Barbiturates
have been occasionally used in the pharmacologic management of elevated
intracranial pressure, although there is little evidence to support
this practice.9–11

Barbiturates are generally classified according to their duration
of action (Table 176-1). The duration of
action depends primarily on their lipid solubility and resulting
distribution into the tissues rather than the elimination half-life.

Barbiturates readily distribute throughout the body to most tissues, crossing
the blood–brain barrier and placenta and being excreted
in breast milk. Fetal blood barbiturate concentrations closely reflect
maternal plasma levels, creating the potential for fetal withdrawal
syndrome.12 Most barbiturates are metabolized in
the liver to inactive metabolites primarily through routes involving ...

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